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Hemorrhagic cyst during pregnancy: Management of ovarian cysts and cancer in pregnancy

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HEMORRHAGE INTO AN OVARIAN CYST SIMULATING ECTOPIC PREGNANCY | JAMA

HEMORRHAGE INTO AN OVARIAN CYST SIMULATING ECTOPIC PREGNANCY | JAMA | JAMA Network










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Article

February 2, 1918


CHESTER H. WATERS, M.D.

Author Affiliations

From the surgical and pathological departments, University of Nebraska College of Medicine.


JAMA. 1918;70(5):295-296. doi:10.1001/jama.1918.02600050017008

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Abstract

The attention of a small group of observers has been attracted to the clinical resemblance of certain ovarian conditions to ectopic pregnancy. The majority of cases recorded have dealt with the formation of a pelvic hematocele of ovarian origin, usually due to rupture and subsequent hemorrhage from a corpus luteum cyst.

The most important ovarian conditions that may suggest ectopic pregnancy are: (1) a corpus luteum or follicular cyst; (2) torsion of the pedicle of a cyst; (3) rupture of a cyst with or without intra-abdominal hemorrhage; (4) ovarian hemorrhage, and (5) hemorrhage into a cyst. Judging from the literature, the last is infrequent, especially as regards its giving rise to symptoms suggestive of ectopic pregnancy.

The exceedingly close simulation of ectopic pregnancy is well shown in the following instance:

History. 
—Mrs. D., aged 28, secundipara, whose labors had been normal, the last one occurring fourteen months before, consulted me,

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Hemorrhagic Ovarian Cyst: A Sonographic Perspective

When a graafian follicle ruptures to release an oocyte, it is transformed into a corpus luteum. The corpus luteum is lined by a layer of granulose cells which rapidly become vascularized; some of these thin-walled vessels can rupture. This causes bleeding into the corpus luteum, resulting in the formation of a hemorrhagic cyst of the ovary.

When internal hemorrhage occurs into functional cysts of the ovary it is called a hemorrhagic ovarian cyst. This occurs most commonly into a corpus luteal cyst, and less often in a follicular cyst.

Pathophysiology: Mechanism of Formation of Hemorrhagic Cysts 

When a graafian follicle ruptures to release an oocyte, it is transformed into a corpus luteum. The corpus luteum is lined by a layer of granulose cells which rapidly become vascularized; some of these thin-walled vessels can rupture. This causes bleeding into the corpus luteum, resulting in the formation of a hemorrhagic cyst of the ovary.

Sonographic Appearances of Hemorrhagic Ovarian Cysts

The appearance of a hemorrhagic ovarian cyst, depends on the stage of formation and duration of the cyst formation.  It can take any of the following appearances:

1) Fishnet weave or fine reticular pattern – This is the commonest presentation of these cysts. There are multiple fine strands of fibrin giving a net-like appearance. This is also called a reticular pattern. The septations in the cyst are typically non vascular on color Doppler imaging and thin.

 

Fishnet or reticular pattern in hemorrhagic ovarian cyst
 
(Image reproduced with permission from www.ultrasound-images.com )

Fine reticular pattern: hemorrhagic ovarian cyst
 

2) Retracting clot appearance – The process of clot formation and subsequent retraction within the hemorrhagic ovarian cyst results in a triangular and somewhat inhomogenous clot in a part of the cyst with serous fluid occupying the remainder of the cyst.

Retracted clot in hemorrhagic ovarian cyst: 

3) Fluid debris level in hemorrhagic ovarian cyst – Another sonographic appearance that may be seen is the fluid debris level within the cyst. The debris is formed by sediment or fine particulate elements within the hemorrhagic ovarian cyst.

4) Rupture of hemorrhagic ovarian cyst – An unusual appearance may be caused by rupture of the hemorrhagic ovarian cyst resulting in blood within the pelvis. This is seen as echogenic fluid surrounding the cyst and uterus. If the hemorrhage is severe there may be hemoperitoneum with blood within the Morison pouch. This appearance can mimic an ectopic pregnancy.

Ruptured hemorrhagic cyst

 

5) Hemorrhagic ovarian cyst resembling a solid ovarian neoplasm – Another form of hemorrhagic ovarian cyst shows echogenic material within the cyst, which usually happens during the subacute period with early stage of clot formation within the cyst. The sonographic appearance in such cases can mimic a solid ovarian neoplasm. Follow-up sonography will show dramatic changes within the hemorrhagic cyst usually in 4 to 6 weeks. Besides color flow imaging will show lack of flow within the hemorrhagic cyst.

Hemorrhagic ovarian cyst simulating a solid ovarian mass
 
(Images 2 to 6 are courtesy of Gunjan Puri, MD, India).

 

Diffferential Diagnosis

Most of the causes of acute pelvic pain can mimic the symptoms and signs of hemorrhagic ovarian cyst. These conditions include acute appendicitis and ectopic pregnancy. Other important differential diagnoses include ovarian torsion, PID (pelvic inflammatory disease) and mesenteric adenitis. Of these, ectopic pregnancy is possibly the most important condition that can mimic hemorrhagic cyst. Serum beta HCG assay with careful examination of the adnexal structures can help distinguish ectopic from hemorrhagic cyst. On probe pressure, the ovary can be seen to move away from the adnexal/ tubal mass in ectopic. The “ring of fire” sign on color Doppler imaging is usually seen in an ectopic pregnancy, but may be also present in hemorrhagic cyst. A positive Beta HCG and pregnancy test can help distinguish ruptured ectopic from ruptured hemorrhagic ovarian cyst.

References:

References:
1) Imaging characteristics of adnexal masses- Lee: (AJR)
2) Ultrasound and CT of pelvic pain  – Andrew Potter (radiographics)
3) Imaging of ovarian masses- Jeong- (radiographics)
4) Sonography of hemorrhagic ovarian cysts – Kiran Jain- (J Ultrasound med)
5) http://www.ultrasound-images.com/ovaries.htm (article on hemorrhagic cysts)

Different types of ovarian cysts – treatment of ovarian cysts before and during pregnancy

The first question that women with suspected cysts ask gynecologists is: can you get pregnant if you have an ovarian cyst? And what types of cysts are incompatible with pregnancy? Patients who have already conceived a child and only after that they learned the diagnosis are concerned about another burning question: is an ovarian cyst dangerous for pregnancy? The answers to all these questions depend on many factors that are discussed in the article.

Different types of ovarian cysts: is it possible to get pregnant?

It is theoretically possible to become pregnant even with an endometrioid ovarian cyst, which is considered the most dangerous variant and in most cases blocks reproductive functions.

A functional cyst (follicular and corpus luteum cyst) in a patient is absolutely not an obstacle to conception and pregnancy. Moreover, often such cysts, without medical treatment, resolve on their own during pregnancy, when the body rearranges its hormonal levels. But still it is better to constantly be observed by a gynecologist.

The best option is to plan the conception of a child in advance, having previously passed all the gynecological examinations that will reveal a cyst.

To avoid unforeseen diagnoses, every woman must visit a gynecologist every six months with an ultrasound of the pelvic organs.

Is it possible to get pregnant with an endometrioid ovarian cyst?

The question of whether it is possible to get pregnant with an endometrioid ovarian cyst is especially relevant for those who want to conceive. Since this particular type of cyst is a very dangerous pathology.

An endometrioid cyst (“chocolate” cyst) is a neoplasm on the surface of the ovary that contains unrejected chocolate-colored menstrual blood (hence the name) in a sheath consisting of endometrial cells.

In the vast majority of cases, endometrioma causes infertility (although there are exceptions). Often, if the endometrioid cyst was asymptomatic, and the woman did not visit the gynecologist for preventive examinations, then infertility becomes the only symptom of endometrioma. With the problem of the impossibility of getting pregnant, the patient goes to the doctor, and only then is the true diagnosis established.

Significantly reduced (or no) chance of getting pregnant with an endometrioid ovarian cyst is due to the following factors:

  • Reduced ovarian reserve due to loss of follicles
  • Hormonal disorders in the ovary and hypothalamic-pituitary system that develop against the background of a growing tumor
  • The development of adhesive processes in the reproductive organs (fallopian tubes, ovaries), which make conception physically impossible, as they prevent sperm from reaching the egg

Also, many women are interested in the question of whether it is possible to get pregnant with an endometrioid ovarian cyst during the IVF procedure. Usually, doctors recommend starting the IVF procedure only after the cyst is completely cured, since it can have a negative impact not only on the process of conception, but also on the bearing of a child.

However, there are cases when endometrioma was detected after a successful IVF procedure and the onset of pregnancy. In this case, an ultrasound examination is performed. If the tumor is small in size, does not compress the organs located nearby, then they do not touch it unless absolutely necessary, since the adhesive process may be aggravated. However, such a patient should be especially closely monitored.

In this case, hormonal, antispasmodic and sedative drugs are prescribed (conservative treatment is extremely important for maintaining early pregnancy). Significantly limited physical activity.

If the endometrioma has grown to a large size, it is better to remove it, because if the cyst is ruptured or torn, an emergency removal operation will be much more traumatic for the woman and her fetus (possible spontaneous abortion) than a planned removal. Laparoscopic removal is usually performed in the second trimester of pregnancy (14-25 weeks).

Removal of an endometrioid ovarian cyst during pregnancy is mandatory if:

  • The size of the cyst reaches 6 cm (or more)
  • Cyst gives pain syndrome
  • The level of tumor markers exceeds the norm

In general, the detection of an endometrioid ovarian cyst already in a pregnant woman indicates that at the time of conception the tumor was at an early stage of development, so it did not have time to disrupt the hormonal balance and ovarian function.

If an endometrioid cyst is discovered during pregnancy planning, it is better to postpone the process of conception until a better time. First, it is recommended to remove the endometrioma by laparoscopy – a minimally invasive method. Then you will have to undergo a course of normalization of the hormonal background after the operation, which will help prevent the appearance of adhesions and the re-development of the tumor (this is possible, since endometrioma is a hormone-dependent formation).

Causes of endometrioid ovarian cysts during pregnancy:

  • Hormonal disorders (excessive production of estrogen and prolactin against the background of a deficiency of progesterone – the corpus luteum hormone)
  • Genetic mutations
  • Immunodeficiencies
  • Excess adipose tissue in the body
  • Endocrine response to stress
  • Menstrual abnormalities (so-called retrograde menstruation, in which blood flows back through the fallopian tubes to the ovaries), which may be due to surgery, abortion or long-term contraception with an intrauterine device

If an ovarian cyst was found already after pregnancy

There are cases when an ovarian cyst is found already in a pregnant girl, and the patient’s question is: “Is it possible to get pregnant if an ovarian cyst is present?” becomes completely irrelevant.

If the cyst is small and does not bother the woman, the patient is simply observed.

In this case, it is not uncommon for a cyst to involute during pregnancy – that is, a reverse reaction develops (the cyst decreases in size until it disappears completely).

This happens because the hormonal balance (due to violations of which the tumor develops) levels out, as the female body throws all its strength into maintaining the process of continuing life. The placenta surrounding the fetus produces a huge amount of progesterone (its lack also affects the formation of cysts). And the body of the expectant mother begins to produce hCG (human chorionic gonadotropin), which stimulates the thyroid gland and its production of hormones.

Pregnancy can proceed normally with an ovarian cyst if the following factors coincide:

  • Cyst not larger than 8 cm (6 cm for endometrioma)
  • Cyst stops growing
  • The level of tumor markers is within the normal range

If at least one factor is disturbed, an operation to remove the cyst is recommended.

The situation is more complicated with patients diagnosed with an endometrioid ovarian cyst, since such a tumor can provoke a miscarriage or termination of pregnancy.

Medical practice records conflicting facts regarding the behavior of endometrioma during pregnancy. There are cases when, under the influence of hormonal changes in the body, the tumor stopped growing. But it happens that a hormonal surge, on the contrary, provoked rapid growth and subsequent rupture of the cyst, which led to an abortion. In addition, the risk of tumor transformation into a malignant form is high.

Treatment of ovarian cysts before and during pregnancy

If doctors detect ovarian cysts at a time when a woman is wondering if she can become pregnant, planned removal (except for small functional cysts) and subsequent long-term hormone therapy are indicated. After such treatment, in most cases, pregnancy successfully occurs.

Laparoscopy is recommended as a removal method, which allows removing the tumor while preserving the ovary, dissecting existing adhesions, and in parallel, diagnosing infertility and its causes.

After treatment of an ovarian cyst, the answer to the question: is it possible to get pregnant often depends on the woman herself, who must regularly see a gynecologist, lead a healthy lifestyle and maintain a positive attitude.

In the case of an acute pathology (rupture or torsion of an ovarian cyst) requiring radical surgical intervention, after surgery, a woman may have difficulty conceiving if adhesions occur in the fallopian tubes (as a complication after surgery) or if one damaged ovary has to be removed. However, if the operation is planned and carried out in a timely manner, then the answer to the question: is it possible to get pregnant after removal of the ovarian cyst, usually turns out to be positive.

Pregnant patients with an ovarian cyst (which happens when pregnancy is not planned) are usually only observed. But in the case of the development of acute pathologies, the medical consultation may prescribe an operation to remove the cyst during pregnancy. In such cases, doctors evaluate the ratio of harm and risk from the cyst to the health of the mother and child.

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Ovarian cyst treatment in St. Petersburg and Vsevolozhsk

Text created with the participation of gynecologist Natalia Dmitrievna Sadova

Ovarian cysts are fluid-filled or other masses that develop in or on the ovary. It is a very common disease that occurs in women of any age. Some patients may experience pain or a feeling of pressure in the pelvis, while others feel absolutely nothing and the mass is an unexpected finding during ultrasound. The disease, as a rule, is benign in nature, but if complications occur, it may require urgent surgical intervention. The specialists of our clinics will help you choose the right tactics and prescribe treatment for an ovarian cyst, if necessary.

Treatment of ovarian cysts is available in the branches:

Treatment of ovarian cysts in the Primorsky district

Address: St. Petersburg , Primorsky district, st. Repishcheva, 13

Treatment of ovarian cysts in the Petrogradsky district

Address: St. Petersburg , Petrogradsky district, st. Lenina, 5

Treatment of ovarian cysts in Vsevolozhsk

Address: Vsevolozhsk , Oktyabrsky Ave, 96

Main types of ovarian masses:

  • Functional:
    • If during the menstrual cycle a dominant follicle is formed, but it does not rupture and release the egg, then the fluid continues to accumulate, forming a follicular cyst.
    • if ovulation has occurred, in the place where the dominant follicle was, a corpus luteum is formed, normally it undergoes regression if pregnancy has not occurred. Sometimes, under the influence of various factors, the reverse development of the corpus luteum does not occur and serous or hemorrhagic fluid begins to accumulate in its place, forming a cyst. A corpus luteum cyst of the ovary can also form during pregnancy. As a rule, it regresses after the formation of the placenta by the second trimester.
  • Dermoid – is congenital and consists of germ cells, and the contents are teeth, hair, fat or other types of connective tissue. A fairly common type, characterized by slow growth and occurs in young women. Usually requires removal of an ovarian cyst.
  • Paraovarian – localized in the wide uterine ligament between the uterus and the ovary, is formed from the supraovarian epididymis. It is not associated with the genitals and often has an asymptomatic course, if it does not reach a large size.
  • Endometrioid – when endometrial cells attach and multiply on the surface of the organ, and then a cavity is formed filled with hemorrhagic contents (old blood). Often, the formations are bilateral, that is, both ovaries are affected. Endometrioid formations are one of the signs of endometrioid disease, that is, they are often combined with adenomyosis, retrocervical endometriosis and endometriosis of the pelvic peritoneum.

Lesions of all types can be unilateral (right ovarian cyst or left ovarian cyst) or bilateral, vary in size (more than 5 cm are considered clinically significant), and contain septa (may be two-chambered or more). Multilocular ovarian cysts are questionable in terms of self-resolving and benign.

It should be noted that in addition to cysts, true tumors or cystadenomas can form in the ovarian tissue, the formation of which is associated precisely with cell division, and not with the accumulation of contents. These include serous and mucinous tumors. They are more likely to malignant, and therefore require surgical treatment.

How ovarian masses present and how to diagnose them

Every third woman is asymptomatic. The symptomatic course is characterized by pain or pressure in the lower abdomen, often on a certain side, pain in the lower back or groin. Pain may be constant or intermittent. With functional formations, women complain of menstrual irregularities (more often – a delay in menstruation or, conversely, spotting begins ahead of time). If the cysts reach large sizes, patients complain of an increase in the size of the abdomen, problems with urination, and a tendency to constipation. Often, only infertility can be a symptom of education, especially for endometrioid tumors.

Detection of pathology occurs during examination on a gynecological chair, but visual diagnostic methods, especially ultrasound, are more important. It will provide the doctor with complete information about the size of the formation, localization, connection with other organs, blood supply, and even structure. All these data make it possible to determine the type of formation, which is very important for determining tactics. Usually, the detection of cysts requires several ultrasound examinations to evaluate their dynamics.

Rarely, CT or MRI may be indicated.

If there is any suspicion of a malignant nature of the disease, the doctor will prescribe a venous blood test for CA-125. The tumor marker is not strictly specific and is not always indicative, but in some situations it allows the doctor to determine correctly. High CA-125 values ​​are also characteristic of endometrioid cysts.

Why ovarian cysts can be dangerous

Given that the formation of an ovary can significantly change its anatomy and affect mobility, and the accumulation of a large amount of content leads to a sharp thinning of the cyst capsule, there may be various complications: torsion of the tumor stem, hemorrhage into the cyst cavity, ovarian cyst rupture, infection and suppuration formations. This also happens against the background of complete well-being, but more often complications are preceded by active physical activity, extreme sports, weight lifting, sexual contact.

In these situations, the woman experiences acute pain that is severe enough to be accompanied by nausea or vomiting. There may be an increase in body temperature, tachycardia, a decrease in blood pressure. If an ovarian cyst bursts, then its contents have an irritating and inflammatory effect on the peritoneum, peritonitis occurs and the functioning of all systems in the abdominal cavity is disrupted. The abdomen becomes painful and tense. With such complaints, you need to urgently call an ambulance and go to the hospital, where an emergency operation will be performed. The scope of intervention may vary.

Endometrial masses have serious reproductive consequences. Due to the fact that they are formed from endometrial tissues, which are hormonally dependent and subject to monthly changes, local inflammation constantly occurs in the ovaries, which changes the functional ovarian tissue – destruction of the follicles occurs. If cysts exist for a long time, then an adhesive process occurs, which affects not only the small pelvis, but also the abdominal cavity. The arrangement of organs in relation to each other becomes abnormal, obstruction of the fallopian tubes often occurs, patients complain of chronic pelvic pain. For such women, it is not possible to get pregnant for a long time, which is the reason for visiting a gynecologist.

Timely treatment of ovarian cysts in women can prevent serious complications and preserve the reproductive organs.

Therapy

Depending on the results of the examination, symptoms, reproductive plans and age of the patient, the doctor may suggest follow-up or surgical treatment of the ovarian cyst.

Expectant management includes monitoring for symptoms and periodically repeating ultrasound every 1.5-2 months. If the formation does not increase or vice versa regresses, then an operation to remove the ovarian cyst is not required.

Conservative treatment does not affect ovarian masses in any way, so it is not used. The appointment of hormonal drugs in order for the functional cyst to resolve is not the right decision: it either regresses on its own, regardless of the appointments, or the hormones will not affect it in any way. However, the frequent recurrence of functional cysts may be a reason to prescribe hormonal contraceptives for prophylactic purposes.

The safety and effectiveness of herbal preparations, vitamins, dietary supplements for resolving the disease has not been proven.

Diagnosis of any formations during pregnancy requires expectant management, if they do not have serious clinical manifestations and there is no suspicion of oncology.

Surgery may be recommended in the following cases:

  • education causes prolonged pain and pressure;
  • the presence of endometrioid cysts, if they interfere with the onset of pregnancy;
  • presence of dermoid formation;
  • Large cysts (greater than 5 cm) are more likely to require surgery, especially if there is a risk of rupture and torsion;
  • lack of education regression for a long time;
  • suspected malignancy of the tumor.

In the presence of any formations on the ovary in women after menopause, it is necessary to exclude the oncological process.

The operation is usually limited to the excision of only the pathological formation and the maximum preservation of the functional part of the ovary, due to which reproductive and hormonal functions are possible. The intervention is carried out in a hospital setting. Laparoscopy of the ovarian cyst is preferable, then all manipulations are performed through several small incisions on the abdomen under the control of a video camera. Access is low-traumatic, without serious cosmetic defects and scars, and recovery after surgery is fast. In the current conditions, open access can be recommended much less often – through a wide incision in the lower abdomen.

Operations:

      • cyst enucleation is the recommended organ-sparing surgery for all women who are still planning a pregnancy. The organ itself is not damaged, only the formation is husked;
      • resection of the ovary – if it is not technically possible to perform only the extraction of a pathological formation, then a part of the organ is excised;
      • oophorectomy or adnexectomy (removal of only the ovary or together with the fallopian tube) – if there is no unchanged functional part of the ovary or if malignancy is suspected. Sometimes such an operation is performed, regardless of the type of formation, if the woman is in pre- or postmenopause.

There are no reliable preventive measures in relation to ovarian formations, therefore, a standard preventive examination by a gynecologist is recommended for all women at least once a year. To avoid both reproductive and quite life-threatening complications that ovarian cysts can create, it is very important to identify them in time and choose the right active or expectant tactics. With this, the specialists of the network of clinics “Dynasty” will definitely help you. In our institutions, you can be absolutely sure of a competent attitude towards your women’s health.

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